User-centred design of a clinical guidelines app

Clinical
guidelines are documents that provide guidance to clinicians when
managing certain medical conditions. At Nottingham University Hospitals
NHS Trust (NUH), there are just under 600 guideline documents stored on
the NUH intranet system. To find the relevant guideline, users must
first locate an available computer and log onto the system, then
navigate through a myriad of links on the Trust website before arriving
at the guideline page. The system is managed by non-clinical staff and
documents are grouped by directorate ownership. The search function for
this system yields many irrelevant results.

The system was not
designed with the user in mind and is particularly impractical during
medical emergencies, when it is both unsafe and time-consuming to leave
the patient’s bedside to access the correct guidelines. The
impracticality of the system has resulted in clinicians not following
the Trust guidelines, a problem that could potentially affect patient
safety and increase litigation risks. There have already been a number
of recorded incidents of near-misses related to the accessibility of
guidelines in the recent past.

Most staff carry a mobile phone
during work, making them an ideal platform for the delivery of critical
information at the bedside in a timely manner. There are already
numerous websites and clinical apps on the market, and clinicians may
choose to use these when treating patients. However, the quality of
information cannot always be verified and may be different from
Trust-approved guidelines. This lack of consistency could potentially
impact on patient safety. We therefore decided to design and develop our
own app to host Trust-approved clinical guidelines for all healthcare
professionals within our Trust.

The main issue with the existing
guidelines system was poor accessibility. We tackled this issue using a
user-centred approach. We sent out an electronic questionnaire to all
clinical staff within the Trust, gathering information about mobile
phone ownership and use of other medical apps in their clinical
practice. Around 520 clinical staff including doctors, nurses, midwives
and physiotherapists responded to the survey. We learned that around 95%
of staff own a smartphone, and over half the group have used it to
access clinical information at least once a week. 89% of staff surveyed
also said they would use a Trust clinical guidelines app if one was
available.

Design specifications

The user
interface for the app has to adapt to the fact that a smartphone does
not have a separate keyboard or mouse. On-screen keyboards are difficult
to type with, and the auto-correct feature on most devices would not
recognise medical terminology. Therefore, we aimed to minimise the use
of the keyboard, and the use of the search function.

The menu
system must be intuitive to navigate. From the outset, we set a target
of making all documents accessible within three clicks of the home
screen. The users must not be buried deep within layers of menu, so that
even if they fail to navigate to their destination at first attempt,
they can very easily find their way back.

We also created a
section called ‘In Case of Emergency,’ where clinical guidelines for
certain emergencies can be accessed quickly. Accessing this feature will
take the user to an A to Z keypad. From here, users will only need to
think of the name of the emergency, and click on the first letter of the
name. This will take the user to final screen where the relevant
guideline may be found.

The users are also able to create their
own list of frequently-used guidelines within the app. In addition,
there is a search function that will generate guidelines using relevant
keywords. To mitigate the issue of mobile black-spots, the content is
accessible offline, with features built-in to ensure it is always up to
date.

User-centred design

We invited all
clinical staff to attend focus groups meetings. In all, around 100 staff
participated in separate sessions. During the meetings we ran card
sorting exercises and critical incidents techniques. In discussion about
the existing system, poorly designed interfaces and an over-powerful
search function generating irrelevant results were identified as common
problems.

For the card sorting exercise, we produced sets of cards
with names of all current Trust guidelines. Participants were divided
into groups and were asked to allocate these cards into the most
relevant specialties. For guidelines that were deemed equally relevant
in more than one group, extra cards were produced and the guidelines
placed in all relevant groups. Participants were also asked to select
guidelines that they thought should be located in the ‘In Case of
Emergency’ section.

Field trial

Based on
the findings during the focus groups, we developed a prototype app for
field testing. The aim was to finalise the layout of the menu structure
and assess usability. We developed a ‘Find the guidelines’ game, where
participants have to find nine different guidelines and other
information using the prototype app. None of the participants had used
the app before and they were not provided with any instructions on how
to use the app. No time limit was set for the test. They were asked not
to use the search function, and to note down their first attempt. When
the correct guidelines are found, instead of opening the document, the
participants were presented with a six-digit code which they were asked
to record on an answer sheet. There were multiple endpoints of each
question, all with a unique code. If no guidelines were found, they were
asked to record the location of where they had expected to find it.
Using this model, a single investigator was able to run the trial with a
large group of participants. At the end of the game, they were invited
to give feedback on the design and their experience of using the
prototype. We continued to modify the prototype during the testing
period. Once the design was finalised we ran further tests and asked
participants to score the app using the System Usability Scale (SUS).

Results

In
all, a group of 102 participants, comprising doctors, nurses and
midwives, participated in the initial field trial. We identified that
all staff groups have different mental models when accessing guidelines.
More experienced staff, including doctors and nurses, were more likely
to use the ‘In Case of Emergency’ button for the clinical emergency
questions, and were also more likely to use medical terminology when
accessing this section of the app. It was difficult to identify the most
appropriate locations for guidelines within the app.

Due to this
difficulty, we redesigned the menu system so that most of the guidelines
may be accessed from multiple locations within the main guidelines
section, and where appropriate, via multiple points of entry in the ‘In
Case of Emergency’ section as well. The app should be designed to fit
all user groups, and the onus should be on us to identify the entry
points suitable for each group.

Once the design was finalised, a
new prototype was produced and we ran the test with a further 43
colleagues. All participants found the app intuitive to use, and were
able find all guidelines easily. This finding is in keeping with the SUS
Score of 83, placing it in the top 5th percentile.

Implementation

The
app was made available on 31st July 2014. It features around 650
guidelines, with over 1300 points of entry. The guidelines are also
searchable using one of 6500+ keywords.

In the first month, we
recorded 763 downloads. The app has been accessed by around 82 unique
users a day since launch. Based on the analytic data so far, less than
9% of hits used the search function as a point of entry, indicating the
success of the menu design.

This is likely to be the first
user-centred design system for managing clinical guidelines. We can see
the potential this has in improving patient safety, and we aim to share
our technology with other NHS Trusts across the country.